Background: Because of lack of good evidence supporting laparoscopic approach for complicated appendicitis, we carried out this study to evaluate efficacy of laparoscopic appendectomy (LA) in management of patients with complicated appendicitis. Materials and Methods: This study was carried out in Surgical Department, Minia University, Egypt involving 214 patients underwent appendectomy for complicated appendicitis over three years. 132 patients underwent LA and remaining 82 patients underwent OA. Parameters studied included operating time, return to oral feeding, postoperative pain, wound infection, intra-abdominal abscess, duration of abdominal drainage and hospital stay. Results: There were four conversions, two due to extensive cecal adhesions and two due to friable appendix. LA took longer time to perform (p = 0.0002) but with less use of analgesics (p < 0.0001), shorter hospital stay (p < 0.0001), shorter duration of abdominal drainage (p < 0.0001) and lower incidence of wound infection (p = 0.0005). Nine patients in LA and seven patients in OA group developed intra-abdominal abscess treated successfully with sonographic guided percutaneous drainage. Postoperative ileus was recorded in two patients in LA group and three patients in OA group, chest infection in one patient in OA group, hernia in one patient in LA and fecal fistula was present in one patient in OA. Overall complications were significantly lower in laparoscopy group and managed conservatively with no mortality in either group. Conclusions: LA in complicated appendicitis is feasible and safe with lower incidence of complications than OA and should be the initial choice for all patients with complicated appendicitis.

Context: The rate of port site complications following conventional laparoscopic surgery is about 21 per 100,000 cases. It has shown a proportional rise with increase in the size of the port site incision and trocar. Although rare, complications that occur at the port site include infection, bleeding, and port site hernia. Aims: To determine the morbidity associated with ports at the site of their insertion in laparoscopic surgery and to identify risk factors for complications. Settings and Design: Prospective descriptive study. Materials and Methods: In the present descriptive study, a total of 570 patients who underwent laparoscopic surgeries for various ailments between August 2009 and July 2011 at our institute were observed for port site complications prospectively and the complications were reviewed. Statistical Analysis Used: Descriptive statistical analysis was carried out in the present study. The statistical software, namely, SPSS 15.0 was used for the analysis of the data. Results: Of the 570 patients undergoing laparoscopic surgery, 17 (3%) had developed complications specifically related to the port site during a minimum follow-up of three months; port site infection (PSI) was the most frequent (n = 10, 1.8%), followed by port site bleeding (n = 4, 0.7%), omentum-related complications (n = 2; 0.35%), and port site metastasis (n = 1, 0.175%). Conclusions: Laparoscopic surgeries are associated with minimal port site complications. Complications are related to the increased number of ports. Umbilical port involvement is the commonest. Most complications are manageable with minimal morbidity, and can be further minimized with meticulous surgical technique during entry and exit.

Context: Spinal anaesthesia has been reported as an alternative to general anaesthesia for performing laparoscopic cholecystectomy (LC). Aims: Study aimed to evaluate efficacy, safety and cost benefit of conducting laparoscopic cholecystectomy under spinal anaesthesia (SA) in comparison to general anaesthesia(GA) Settings and Design: A prospective, randomised study conducted over a two year period at an urban, non teaching hospital. Materials and Methods: Patients meeting inclusion criteria e randomised into two groups .Group A and Group B received general and spinal anaesthesia by standardised techniques. Both groups underwent standard four port laparoscopic cholecystectomy. Mean anaesthesia time, pneumoperitoneum time and surgery time defined primary outcome measures. Intraoperative events and post operative pain score were secondary outcome measure. Statistical Analysis Used: The Student t test, Pearson's chi-square test and Fisher exact test. Results: Out of 235 cases enrolled in the study, 114 cases in Group A and 110 in Group B analysed. Mean anaesthesia time appeared to be more in the GA group (49.45 vs. 40.64, P = 0.02) while pneumoperitoneum time and corresponding the total surgery time was slightly longer in the SA group. 27/117 cases who received SA experienced intraoperative events, four significant enough to convert to GA. No postoperative complications noted in either group. Pain relief significantly more in SA group in immediate post operative period (06 and 12 hours) but same as GA group at time of discharge (24 hours). No late postoperative complication or readmission noted in either group. Conclusion: Laparoscopic cholecystectomy done under spinal anaesthesia as a routine anaesthesia of choice is feasible and safe. Spinal anaesthesia can be recommended to be the anaesthesia technique of choice for conducting laparoscopic cholecystectomy in hospital setups in developing countries where cost factor is a major factor.

Background: Authors report incise, dissect, excise and suture (IDES) technique of laparoscopic repair of paediatric male inguinal hernia (LRPMIH). This series retrospectively evaluates a consecutive personal series of children undergoing laparoscopic hernia repair by this new technique. Materials and Methods: It is a retrospective review of the LRPMIH done by single surgeon from January 2001 to December 2007. All male patients who were referred to the first author for management of inguinal hernia were given the option of laparoscopic repair. Parents who gave consent for their child to undergo LRPMIH were retrospectively reviewed. Results: A total of 155 patients were operated. Age group was 2 months to 13 years (average-5 years). Follow-up period ranges from 1 to 7 years. Average operating time was 29 min for unilateral and 40 min for bilateral inguinal hernia. Maximum time required was 50 min which was for bilateral inguinal hernia. Bilateral inguinal hernia was present in 10 (6.4%) patients. There were no intraoperative complications. Contralateral processus vaginalis was patent in 25 (16.12%) patients. In the immediate post-operative period 8 patients had port site surgical emphysema which resolved on its own. There are no recurrences so far. One patient developed port site hernia, which was repaired with the standard surgery. There is no incidence of clinical testicular atrophy. Conclusion: LRPMIH can be done as routine procedure and also has fewer complications. It has advantage of diagnosing and repairing contra lateral patent processus vaginalis. However a double-blind controlled study is required to establish the results.

SILACIG: A novel technique of single-incision laparoscopic appendicectomy based on institutional experience of 29 cases

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SK Uday, P R K BhargavDOI:10.4103/0972-9941.110967 PMID:23741113

Introduction: More reports of single-incision laparoscopic appendectomy are appearing in literature as it is an improvement over multiport laparoscopy in further reducing the trauma to abdomen. But, most of techniques require expensive gadgets like commercial ports and manoeuverable instruments, which are not available at many centres. In this context, a feasibility study of our own operative technique of single-incision laparoscopic appendectomy with less expensive conventional instrumentation was conducted at a single centre. Materials and Methods: This prospective study was carried out in tertiary care teaching institute of a semi-urban area in South India over a period of 1 year from March 2011 to February 2012. Twenty-nine patients of appendicitis were included in this study. Based on the principles of single-incision laparoscopy, we developed a glove port utilizing readily available operation theatre equipment. Results: Mean operative time was 56±12 minutes. Mean age of subjects was 34±15 years. M: F ratio was 2:1. There was no significant perioperative morbidity or mortality. Mean follow-up period was 8 months. Conclusion: Our initial experience with this technique of single-incision laparoscopic appendectomy demonstrates its feasibility, safety at a very low cost.

Foreign bodies inside the pancreas are rare and usually occur after the ingestion of sharp objects like fish bone, sewing needle and toothpick. Most of the ingested foreign bodies pass spontaneously through the anus without being noticed but about 1% of them can perforate through the wall of stomach or duodenum to reach solid organs like pancreas or liver. Once inside the pancreas they can produce complications like abscess, pseudoaneurysm or pancreatits. Foreign bodies of pancreas should be removed by endoscopic or surgical methods. We hereby report our experience of successful removal one a sewing needle from pancreas.

Intussusception after Roux-en-Y gastric bypass is more common than previously believed. It usually occurs between one and three years post-operatively, though we present a case that presented with a retrograde intussusception necessitating bowel resection seven years after a laparoscpic Roux-en-Y gastric bypass. The diagnosis and etiological theories are discussed based on findings from the literature.

Lymphangioleiomyomatosis with tuberous sclerosis complex is a rare disease. One of the most frequent complications of lymphangioleiomyomatosis is pleural effusion (chylothorax) wich can be treated with the use of VATS. Authors report a case of pulmonary lymphangioleiomyomatosis in a 56-year-old female patient with tuberous sclerosis complex with an 8-week history of recurrent chylothorax, dyspnea and debilitating weakness. By CT scan a flat tissue proliferation was seen in the site of the thoracic duct and it was supposed to be the reason for the pleural effusion. A VATS resection of this laesion and ligation of the thoracic duct was performed successfully. Chylothorax is often associated with pulmonary lymphangioleiomyomatosis. Lymphangioleiomyomatosis combined with tuberous sclerosis complex is extremely rare. In case of chylothorax VATS treatment is successful and may be the first choice.

Introduction: Experience has allowed increasingly complex procedures to be undertaken by single port surgery. We describe a technique for single port Billroth I gastrectomy with a hand-sewn intracorporeal anastomosis in the resection of a benign tumour diagnosed incidentally on a background of cholelithiasis. Materials and Methods: Single port Billroth I gastrectomy and cholecystectomy was performed using a transumbilical quadport. Flexible tipped camera and straight conventional instruments were used throughout the procedure. The stomach was mobilised including a limited lymph node dissection and resection margins in the proximal antrum and duodenum were divided with a flexible tipped laparoscopic stapler. The lesser curve was reconstructed and an intracorporal hand sewn two layer end-to-end anastomosis was performed using unidirectional barbed sutures. Intraoperative endoscopy confirmed the anastomosis to be patent without leak. Results: Enteral feed was started on the day of surgery, increasing to a full diet by day 6. Analgesic requirements were a patient-controlled analgesia morphine pump for 4 postoperative days and paracetamol for 6 days. There were no postoperative complications and the patient was discharged on the eighth day. Histology confirmed gastric submucosal lipoma. Discussion: As technology improves more complex procedures are possible by single port laparoscopic surgery. In this case, flexible tipped cameras and unidirectional barbed sutures have facilitated an intracorporal hand-sewn two layer end-to-end anastomosis. Experience will allow such techniques to become mainstream.

Introduction: Surgery has the potential to remove the entire hydatid cyst and can lead to complete cure. Presence of hydatid cysts in multiple abdominal organs imposes special challenges for laparoscopic management. The patient position and port placement for one organ may not be adequate for other and proper exposure in hydatid cyst is of paramount importance to prevent spillage and complete removal of the cyst. Single incision multi-trocar technique has a unique advantage of allowing surgeon to work in different quadrants of abdomen using the same incision and ports. We report in this paper the first Laparo-endoscopic single-site hepatic cyst excision with partial splenectomy for hydatid cyst in liver and spleen using conventional laparoscopic instruments. Patient and Technique: The procedure was performed on a 64 year old female diagnosed to have Hydatid cyst in segment VIII of liver and another cyst in lower pole of spleen a transverse 3 cm incision was made 6 cm above umbilicus and was deepened up to fascia. Two 10mm and one 5mm ports were inserted. Procedure was completed in 160 minutes without any intra-operative complication. There were no post-operative complication and patient was discharged on day 5. Conclusion: Single incision multi-trocar surgery has cosmetic advantage over standard laparoscopic approach. It is even more marked when two procedures are combined in different quadrants of abdomen. As this is a rare combination procedure so it remains to be determined if this technique offers additional advantages of decreased analgesia, decreased hospital stay or cost effectiveness.

Background: Intraperitoneal onlay mesh repair is an established modality to treat large ventral hernias. Various techniques of laying the mesh are utilized. We present the Double Rolling and Center Hitch technique to lay a large intraperitoneal onlay mesh. Objective: The aim of the study is to devise and adopt a method to reduce the difficulty in manoeuvring a large mesh inside the peritoneal cavity. It should also help in correct placement of mesh and decrease the operative time. Materials and Methods: The DRACH technique was used in eighteen patients with large ventral hernias between May 2010 and September 2011. The Mesh size used was 15x20cm and more (considered to be large mesh). Results: All the procedures were completed successfully. Mesh handling was significantly easier with the DRACH technique. The average mesh deployment time (MDT) was 15mins. In all cases the mesh was adequately centred with a margin of 3-5cm from the defect. Conclusion: The DRACH technique can be employed to lay large intraperitoneal meshes in order to reduce the handling difficulties associated with large meshes, and to aid in better placement of meshes so as to centered over the defect.